A nurse is planning to transfer a client who weighs 136 kg (300 lb) from a bed to a chair. The client is unable to assist in the transfer. Which of the following actions should the nurse plan to take?

Choice A reason: Restricting fluids to 1,200 mL per day is not indicated post-hernia repair unless specific conditions like heart failure exist. Adequate hydration supports recovery and prevents complications like constipation. This restriction is arbitrary and potentially harmful, making it an incorrect plan component.
Choice B reason: Encouraging deep breathing exercises every 2 hours prevents pulmonary complications like atelectasis or pneumonia, common risks post-hernia repair due to anesthesia and pain-limited breathing. This promotes lung expansion and oxygenation, aligning with evidence-based postoperative care, making it the correct intervention.
Choice C reason: Applying a warm compress to the surgical site is not recommended, as it may increase swelling or risk infection in the early postoperative period. Cool compresses, if needed, reduce edema. This intervention lacks evidence and could harm healing, making it inappropriate.
Choice D reason: Limiting ambulation for 48 hours delays recovery, as early mobility post-hernia repair reduces complications like thromboembolism and promotes healing. Patients are typically encouraged to walk within hours, making this restriction counterproductive and against standard postoperative protocols, thus incorrect.

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.